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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .-, 7/ltd <br /> 77-gg'O-t' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -?-d,2-7J <br /> 1 (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein e i pd. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and -511,1t Regula ns the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS;TRACT <br /> Owner's Name Phone <br /> Address City <br /> r s D hone <br /> F <br /> Contractor's Name <br /> License 1� <br /> L <br /> TY - <br /> WORKt�(Check) : NEW WELL /4j EtPEN-/ / RECONDITION_/ / DESTRUCTION /? <br /> PUMP INST—AZLATIONo�/- PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> f other <br /> DISTANCE TO NEAREST: SEPTIC TANK ',,SEWER L ES PIT PRIVY �`— <br /> � • SEWAGE DISP SAL FIEND/&U C SSPOOL/SEEPAGE PIT OTHER <br /> T. PROPER---LINE--l-PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL - <br /> INTENDED <br /> ELL -INTENDED USE 'TYP•E- OF WELL' CONSTRUCTION SPECIFICATIONS <br /> Industrial' Cable 'Tool Dia. of Well Excavation / <br /> �D`amestic/private Drilled Dia. of Well Casing ` <br /> '+< Domestic/public ri-/- , Driven; Gauge of Casing ! <br /> Irrigation Gravel' Pack Depth of Grout Sea <br /> Cathodic Protection--`;t__L,=-Rotary Type of Grout <br /> ` Disposal A Other i Other Information --. <br /> Geophysical --- 5 ace Seal Ie B �. <br /> ns <br /> PUMP INSTALLATION: Contractor <br /> Type of Pu _ • . <br /> PUMP REPLACEMENT; State Work Done <br /> } <br /> PUMP .REP:SIRcv <br /> — "" Sfate Work-Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sari Joaquin Local Health District <br /> j and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above <br /> infoion is true to be t f- my.-knowledge and belief.. I WILL CALL FOR A GROUT INSPECTION <br /> 4 PRIOR ROUTING AN FT S <br /> SIG TITLE 0 ^ <br /> PLAN ON RE FRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> P II GR UT INSPECTION PVAP I FINAL INSPECTION <br /> INSPECTION B DATE S -INSPECTION B DATE <br /> 0 +'+ rr-. , s 3/76 2m <br /> E H 1426 Rev. 1-74 <br />